Forrest C B, Weiner J P, Fowles J, Vogeli C, Frick K D, Lemke K W, Starfield B
Health Services Research and Development Center, Johns Hopkins School of Public Health, 624 N Broadway, Room 689, Baltimore, MD 21205USA.
JAMA. 2001 May 2;285(17):2223-31. doi: 10.1001/jama.285.17.2223.
Most health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan.
To comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care.
Retrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan.
Self-referred service use and charges, reasons for self-referral, and satisfaction with specialty care.
Overall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received.
Having the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.
大多数健康维护组织提供了对患者获得专科护理限制较为宽松的产品。其中一种产品是服务点（POS）计划，该计划将“把关”安排与患者自费直接转诊的能力相结合。关于这种新型计划的正式评估数据很少。
通过量化自我转诊率、识别最有可能自我转诊的患者、描述患者自我转诊的原因以及评估对专科护理的满意度，全面描述POS计划中的自我转诊过程。
采用回顾性队列分析，使用行政数据库，这些数据库由1996年在中西部（n = 265843）、东北部（n = 80292）和中大西洋地区（n = 39888）参加3个POS健康计划6至12个月的0至64岁成员组成，并对中西部计划的专科护理使用者（n = 606）进行了1997年的电话调查。
自我转诊的服务使用情况和费用、自我转诊的原因以及对专科护理的满意度。
总体而言，中西部POS计划中有8.8%的参保人、东北部计划中有16.7%的参保人以及中大西洋计划中有17.3%的参保人至少自我转诊过1次去看医生或非医生临床医生。在所有3个计划中，自我转诊去看全科医生的参保人比例（4.7%-8.5%）略高于自我转诊去看专科医生的比例（3.7%-7.2%）。总费用的9%至16%归因于自我转诊。患有慢性疾病和骨科疾病的患者、医生批准服务的费用分担较高以及与他们的常规医生连续性较差的患者，自我转诊去看专科医生的可能性增加。自我转诊去看专科医生的患者中，38%的人更喜欢直接获得专科护理，28%的人报告与他们的常规医生关系有问题，23%的人与专科医生有持续关系，8%的人对保险规则感到困惑，3%的人没有常规医生。与由医生转诊去看专科医生的患者相比，自我转诊的患者对他们接受的专科护理更满意。
对于大多数POS计划参保人来说，有自我转诊的选择就足够了；在1年的时间间隔内，93%至96%的参保人没有行使他们通过自我转诊获得专科护理的POS选项。POS健康计划中未经协调的自我转诊服务使用的潜在不利影响是有限的，并且被患者对专科服务更高的满意度所抵消。
